Achy Left arm/ Palpitations/ Holter results

[tarek]

I have posted before regarding chest pains/palpitations/achy left arm. (I’m male/ 24). Previous all normal-tests: Stress test with Echo, regular echocardiogram (EF 70%), chest x-ray, blood studies (with thyroid normal)

I had a 48 hours Holter done and I am concerned about the report which said:

1. The rhythm included 19 hours of bradycardia  (less than 50bpm) with the slowest at 43bpm lasting 2 minutes at 4:25am à I can see from the strip that most of these were while sleeping but that during the day it also sometimes ran in the 50’s and sometimes high 40’s, is this normal or is too low? (I’m no athlete)
2. The rhythm included 2 hours of tachycardia à 1 hour was from exercise but I bought a polar monitor to see whats going on with my heart rate. I noticed for example at night my pulse is around 50  but when I stand and walk around it will shoot up to 90-100 for 3-4 seconds then settle down. Is this a normal variant?
3. Supraventricular ectopic activiy consisted of 46 beats
a. 2 were in atrial couplets
b. 28 were late beats
c. 14 were single PACs
d. Longest pause was 1.7 seconds which took place at 5am

Are these 2 atrial couplets normal and is the 1.7 pause something of concern?

I discussed the results with the cardiologist and he says that there’s nothing seriously wrong (which really did not assure me) and then told me I was too young and no need for a pacemaker. He doesn’t want to do anything invasive (like EPS).

Please I understand this is just the Internet and that you do not have all the data at hand but what do you think I should do?

[CCF-M.D.-BJ]

tarek,

Thanks for the post.

1. The rhythm included 19 hours of bradycardia (less than 50bpm) with the slowest at 43bpm lasting 2 minutes at 4:25am à I can see from the strip that most of these were while sleeping but that during the day it also sometimes ran in the 50’s and sometimes high 40’s, is this normal or is too low? (I’m no athlete)

This isnt out of the ordinary for a healthy young man.

2. The rhythm included 2 hours of tachycardia à 1 hour was from exercise but I bought a polar monitor to see whats going on with my heart rate. I noticed for example at night my pulse is around 50 but when I stand and walk around it will shoot up to 90-100 for 3-4 seconds then settle down. Is this a normal variant?

Not a normal variant....its normal.

3. Supraventricular ectopic activiy consisted of 46 beats
a. 2 were in atrial couplets
b. 28 were late beats
c. 14 were single PACs
d. Longest pause was 1.7 seconds which took place at 5am

Are these 2 atrial couplets normal and is the 1.7 pause something of concern?

This is all within what you would see in a normal holter.

I discussed the results with the cardiologist and he says that there’s nothing seriously wrong (which really did not assure me) and then told me I was too young and no need for a pacemaker. He doesn’t want to do anything invasive (like EPS).

From what you mention there would be no reason for an EPS.

Please I understand this is just the Internet and that you do not have all the data at hand but what do you think I should do?

I dont know what else to tell you. Its obvious you are very concerned with this despit reassurance form your physician. If a second opinion cant alleviate your anxiety, then perhaps looking at the cause of your anxiety may be a good route to take.

good luck

[tarek]

Thank you in advance..

[anacyde]

I have PACs and atrial couplets, as well as paroxysmal supraventricular tachycardia (PSVT).  Those, in the setting of a structurally normal heart, are not anything to worry about.

[PikaPika88]

My heart "Pause" for 3.2 sec at 2:14pm.  Cardio said the holter report "it doesn't make sense!"  I also have many other numbers there.  Cardio sound like I passed with flying colour.  See me 6 months around April next year.

[PikaPika88]

My holter report actually has 6 sections reporting the heart events.  There are: Heart Rate, ST Segment Analysis, Ventricular Ectopy, Supraventricular Ectopy, Heart rate Variability and Bradycardia, QT.  So I think and hope that they won't stuff up the SVT with ST.

[tarek]

Thank you doctor for your quick response, as well as everyone who responded... this information sharing alleviated many of my concerns...

[micheller]

Hi anacyde, I read your comment about what youve been diagnosed with.  I have been trying to post, and will continue, but wanted to ask some other people.  I was just recently diagnosed last week from a 24 hour holter with "2 brief episodes of SVT, rate 154, exercise induced? Otherwise normal 24hr study"  My Dr. wants me to go see an Electrophysiologist, and was talking about him doing an EP study and ablation.  She has me terrified, and then I see other people online that don't do anything about it.  Did your Dr. recommend you do an EP study?  I would just like to try medication first and then go from there.  I'm just not ready for anything invasive just yet.  Also, does anyone know if they can possibly misdiagnose svt from regular st on a holter?  Thank you! Michelle

[tickertock]

Just want to say I agree totally with mmfd comments, though I'm not a medical doctor. From what I gather the vast majority of persons that would present with your holter report would be declared as essentially normal. Nearly everyone has some minor arrhythmia and while it is distressing to those who feel them, it would probably be more alarming to have a perfect regular rhythm. Just my 2cents! As a lifelong sufferer of PVCs/Pacs and Tachycardia, 3 different cardiologists and one EP has advised me that an EP study and possible ablation for my problem would be bordering on malpractice and is not warranted, bear in mind that my condition does not reflect what your problem might be, but if I were you a second or third opinion might be well warranted.Good luck.

[PikaPika88]

I hope Tarek don't mind that we're sharing his thread.  I tried a lot of times but didn't give me a second chance.  

Anyone knows?  Is this a normal Holter Report?  Or my pacemaker is on strike or slow work?  It didn't ask for Pay Raise though!

If you got one holter report, could you post here and let me know what yours Dr's comments are?


ECG
? Pacemaker induced rhythm rate about 70 bpm.

HEART RATE
Minimum HR-4 Intervals : 56 bpm at 16:13
Maximum HR-4 Intervals : 121 bpm at 9:01
Average HR-24 Hours : 77 bpm
Minimum HR-Hourly : 69 bpm at 7:00
Maximum HR-Hourly : 105 bpm at 14:00
Analyzed Beats : 58253
Analyzed Minutes : 1154

ST SEGMENT ANALYSIS
Total ST Minutes CH1 : 0
Total ST Minutes CH2 : 17
Total ST Minutes CH3 : 0
Max Delta ST Depression : -1.6 at 21:19 @ CH2
Max Delta ST Elevation : +1.9 at 6:14 @ CH2
Max ST Episode : 5 Minutes at 9:28
Max HR In ST Episode : 96

VENTRICULAR ECTOPY
VE Total : 796
V-Pair Total : 41
V-Run Total : 28  
Longest V-Run : 18 beats at 12:17
Maximum HR V-Run : 144 bpm at 15:35
Minimum HR V-Run : 83 bpm at 12:18
VE's per 1000/per Hour : 14/40
Ventricular R on T : 25

SUPRAVENTRICULAR ECTOPY
SVE Total : 270  
SV-Run Total : 11
Longest SV-Run : 6 beats at 11:04
Maximum HR SV-Run : 253 bpm at 14:02
SVE's per 1000/per hour : 5/14
Total Aberrant Beats/Runs : 32/0
Atrial Fib/Flutter : N/A

HEART RATE VARIABILITY
SDNN-24 Hour : 82
SDANN Index : 71
SDNN Index : 45
rMSSD : 44
pNN50 : 19
Spectral Power-24 Hour : (Blank)
Min Spectral Power Hour : (Blank)
Max Spectral Power Hour : (Blank)

BRADYCARDIA
Pauses in Excess of 2.5 sec : 1
Max Pause : 3.2 sec at 14:14

QT
Max QT : 576 ms (Ch.3)
Max QTc : 630 ms
Time of Max QT/QTc : at 04:44. HR 72 bpm.
Ventricular Escape : N/A

[micheller]

Hi there, what does your test mean?  That is a lot of things going on.  So were you diagnosed, or not with SVT?  I am just curoius about whether SVT has to be treated with an EP study or if they can start you on meds first.  I only had two brief episodes, and the longest run was 6 beats!!  My Dr. is already talking EP study and ablation? I did however, Under the Supraventricular Events, have 56 couplets, do you know what that means?  Total Beats was 236.  I'm so confused and I have been waiting for a week to have my Dr. call me back and I'm getting frustrated. Sorry for talking under someone elses thread, just would love to hear everyone elses experience with this.  Thank you! Michelle

[mmfd]

Well, in my opinion, I think anyone who would do an EP study on you would be jumping the gun a tad!  You don't need meds either for 2 very very short 6 beat runs of SVT.  It is not life threatening in any fashion, even if the runs lasted several hours.  Meds can have  side effects, and shouldn't be given without a real need for them.  Maybe you could try changing some stuff like your diet to eliminate triggers like caffeine, chocolate, etc. and limiting stress, lack of sleep, and see if you get any more.  Try to relax, as you might never have this again, and even if you do it can be dealt with easily.  An EP study is not without risks, and again, in my opinion, some doctors are too eager to practice their ablation techniqes!

[micheller]

Hello, thank you so much for talking to me!  I kind of think it is a little weird too, except my Dr. says the holter said exercise induced so that kind of bothers her?  The two episodes I remember were really stressful, one was chasing my dumb horses who got loose, and the other I hate a LOT, I mean a LOT of chocolate and then a 7-up and then ran really fast outside to the mailbox.  I am very out of shape, even though my weight is perfect.  I have mild MVP, and very mild asthma.  My problem is my panic and uncontrolled stress due to things in my life I can't control.  I have had these fast beat "episodes" before, and they were ALL during times when I had something extremely stressful to do or that I didn't want to do (like going to the Dentist, or watching my son in a wrestling tournament) They always go away on their own within 5 minutes, but I'm not saying they were even SVT.  Only that I get extremely fast rates and they skip too when I have a panic attack.  My mom is an RN, and one of my friends is a heart nurse, and they are so quick to tell me to get in and do the EP study, even though they both told me of course my stress needs to be controlled.  I'm so frustrated. Michelle

[micheller]

Hello, thank you for your opinions.  I really appreciate it.  I wonder why my Dr. and mom are making such a big deal.  It doesn't help my anxiety disorder.  
tickertock, do you have sinus tach, or svt?  Once they "see" if on a holter, what comes next?  My Dr. doens't know, other than to see a Cardiologist/Electrophysiologist.  I am hoping they look at it and say, "no big deal".  I've never noticed or worried too much before about my fast heart rate because it was always at stressful times. By the way, can extreme stress cause svt?  My friend says no, but then I wondered if she was wrong?  I've been more troubled by the dumb pac's and pvc's, and sometimes want a beta blocker to help with those.  Thanks! Michelle

[tickertock]

It has been identified as paroxysmal tachycardia because it can start and stop suddenly meanly usually initiated with a PVC, sometime the PVCs and tachycardia occur together at the same time, now that's scary, its been captured on ECG , though the rhythm as always been identified as sinus tachycardia or sinus tachycardia with PVCs, never did have to get injection to stop it, just an oral beta blocker would do the trick even if the PVCs persisted. Like I said Ive seen several cardiologists and a very reputable EP who told me since they basically know what my rhythm is and have captured it on ECG , an EP study and and ablation is not warranted in my case as the benefits would not out weigh the risk, my situation might be completely different, if in doubt get a second or even third opinion.Nearly every doctor/cardio/EP Ive seen has told me the same thing so I think i can go on that.GOOd luck.

[micheller]

Hello again, my Dr. called and after talking to either a Cardiologist or an Internist (I don't know which) over my holter results, they don't think an EP study is right at all either.  They think a low dose beta blocker and my Xanax is right for me.  I get the pac's and pvc's quite a bit, but I know what you mean when you get the tachy and pac's, that is what happens to me and scary!  When I have an anxiety attack, my heart rate goes up, when it hits about 150, it does a pac, then kicks in the svt.  For me it seems to be adrenaline induced, if there is such a thing?  Unfortunately, due to some severe stress in my life right now, it seems like my heart rate is always around 100-130.  Anyways, I feel a little better knowing I'm not going to die.  I was told previously that you had to have an ep study done just to know what kind of svt you had so you knew it wasn't deadly, and they couldn't tell what kind of svt it is just by an EKG strip.  Take Care, Michelle

[tickertock]

EP studies are usually recommended if they can't catch the SVT/pacs/pvcs on an ECG tracing. It is true that some of types of SVT can usually only be found/identified during an Ep study, usually a concealed accessory pathway or multiple pathways . In general these SVTs are not life threatening by merely a nuisance, WPW is the one SVT that can be potentially life threatening, usually a-fib has to occur with this for it to be since with WPW the atria has a direct link with the ventricles and can conduct at a 1:1 ratio which can result extremely fast ventricular rates and degenerate into v-fib. This is a very rare event from what I understand. WPW is usually manifest on a ECG  with a short PR interval, a widen QRS, and a delta wave. If you don't present with either of these on ECG I wouldn't worry at all, they are concealed forms but they rarely result in ventricular preexcitation as in manifest WPW.Bear in mind I'm not a medical doctor. The beta blocker atenolol has worked well for me, no tachycardia event at all while taking it.It might be worth giving the beta blocker a try and see what happens. Good luck.